The American Academy of Neurology (AAN) 2019 migraine treatment guideline for children and adolescents provides recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioural therapy (CBT) in the paediatric population.

As per the American Academy of Neurology (AAN), a majority of randomized controlled trials studying the efficacy of preventive medications for paediatric migraine fail to demonstrate superiority to placebo. Prevention strategies for migraine in children should include counselling on lifestyle and behavioural factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence.

Migraine is commonly observed in children and adolescents. While most children benefit from acute migraine treatments along with behavioural and lifestyle changes, additional migraine prevention strategies should be considered in cases where headaches occur with sufficient frequency and severity and result in migraine-related disability.

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Counselling and education for children and adolescents with migraine and their families

Family history and female sex are high risk factors for the development of migraine that persists into adulthood. Disease prevention should be the main goal of migraine management.

A number of behavioural factors can influence the frequency of headaches in migraine. Recurrent headache in adolescents have been associated with the following factors:

• Being overweight
• Caffeine and alcohol use
• Lack of physical activity
• Poor sleep habits
• Tobacco exposure

Depression is also related with higher headache disability in adolescents.

Identifying and avoiding the causative factor can help reduce the frequency of migraines; for example reducing weight can lead to headache reduction in children who are overweight.

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Starting preventive treatment

As per the guideline panel, the majority of randomised controlled trials that studied the efficacy of preventive medications for paediatric migraine fail to demonstrate superiority to placebo (with studies demonstrating a high response to placebo).

Topiramate: Topiramate has been found to decrease the number of days with headache and the frequency of migraine attacks in paediatric population; however, there is lack of evidence for 50% reduction in migraine frequency or headache days, and reduction in migraine-related disability with the use of topiramate.

Propranolol: The benefit of propranolol in 50% reduction in headache frequency in paediatric migraine patients is well established in clinical studies.

Amitriptyline: Children administered amitriptyline in combination with CBT are more likely to experience a decreased headache frequency. These patients are also found to have more than a 50% reduction in headache frequency and a decreased migraine-associated disability. It should be noted that amitriptyline carries a Food and Drug Administration (FDA) black box warning regarding risk of suicidal thoughts and behaviour especially in children, adolescents, and young adults. The panel suggest that it is possible that CBT alone is effective in migraine prevention, and individual barriers to access may exist.

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Counselling for patients of childbearing potential

Topiramate and valproate are well-known teratogenic drugs; additionally, prenatal exposure to valproate may lead to developmental disorders in the offspring. Topiramate at higher doses are also known to interact with oral combined hormonal contraceptives.

Preconceptional folic acid supplementation is recommended for childbearing women, as it reduces the risk of major congenital malformations.

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Monitoring and stopping medication

As migraine is a chronic disorder associated with spontaneous remissions and relapses, a lot of variability is observed in the information regarding the exact duration for which the preventive treatment should be continued; same holds true for data regarding the risk of relapse after discontinuation.

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Mental illness in children and adolescents with migraine

There is a lack of consistent evidence for the association of mental illness in children and adolescents with migraine. A recent systematic review assessed the prognostic factors for recurrent headaches in children and adolescents. As per the review, there is high evidence that children with negative emotional states, manifesting through anxiety, depression, or mental distress, are not at greater risk of developing recurrent headache; however, it found moderate-quality evidence that suggested the presence of comorbid negative emotional states in children with headache is associated with an increased risk of headache persistence in those who already experience recurrent headaches.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.